Email*

First name

Last name

Phone number

Street address

City

State/Region

Funding Type Request?

Settled or Pending Case?

Lawsuit Filed? Offer Made?

In Mediation or Scheduled For?

Demand Letter Sent? On Appeal?

Case Description? What Happened? Location and Date of Incident?

Attorney Name, Firm, Phone, Fax, Address

When is this supposed to settle or pay? What is the estimate of settlement amount? What is the case worth?

What medical bills to date? Injuries, surgeries, MRI, hospital? Still in treatment?

In bankruptcy? Any liens against the settlement? Previous advances (what company and how much)?

How much of an advance do you need or want (minimum amount)? How soon do you need it?

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